1
Q
How has the management of hypoglcaemia recently changed?
A
used to use IV 50% glucose a lot but increases risk of extravasation injury - now tend to use 10% or 20% glucose instead
2
Q
On what basis should IV glucose preparations be prescribed for patients with diabetes?
A
IV glucose should be prescribed on an ‘as required’ (PRN) basis for all patients with diabetes
3
Q
What drugs don’t always need a prescription when given in a hypoglycaemic emergency?
A
glucagon (and IV glucose) may be given without prescription in an emergency for the purpose of saving a life (if agreed locally)
4
Q
What is the only situation when IM glucagon is licensed for?
A
the treatment of insulin overdose (but also used in treatment of hypoglycaemia induced by sulfonylurea therapy)
5
Q
What is the definition of mild hypoglycaemia?
A
lower than normal level of blood glucose, in which the episode is self-treated
6
Q
What is the definition of severe hypoglycaemia?
A
loewr than normal level of blood glucose, where assistance by a third party is required
7
Q
What is considered the lower limit below which any blood glucose should be treated for hypoglycaemia?
A
<4.0 mmol/L
8
Q
Which type of diabetes is hypoglycaemia more common in?
A
T1DM more so than T2
9
Q
In which type of diabetes are patients more likely to be admitted to hospital with hypoglycaemia?
A
insulin-treated type 2 diabetes
10
Q
What is the level at which hypoglycaemia is termed ‘significant’ hypoglycaemia?
A
<2.9 mmol/L
11
Q
What is the definition of nocturnal hypoglycaemia?
A
<3.9 mmol/L
12
Q
What are 3 groups that clinical features of hypoglycaemia can be classed into?
A
- Autonomic
- Neuroglycopenic
- General malaise
13
Q
What causes autonomic symptoms in hypoglycaemia?
A
activation of the sympatho-adrenal system
14
Q
What causes the neuroglycopenic symptoms of hypoglycaemia?
A
result of cerebral glucose deprivation
the brain is dependent on a continuous supply of circulating glucose as the substrate to fuel cerebral metabolism and to support cognitive performance; if blood glucose levels fall sufficiently, cognitive dysfunction is inevitable
15
Q
What scoring system scores the presence of clinical features of hypoglycaemia?
A
Edinburgh Hypoglycaemia Scale
16
Q
What are 4 autonomic symptoms of hypoglycaemia?
A
- Sweating
- Palpitations
- Shaking
- Hunger
17
Q
What are 5 neuroglycopenic symptoms of hypoglycaemia?
A
- Confusion
- Drowsiness
- Odd behaviour
- Speech difficulty
- Incoordination
18
Q
What are 2 general malaise symptoms of hypoglycaemia?
A
- Headache
- Nausea
19
Q
What 3 groups can risk factors for hypoglycaemia be classed into?
A
- Medical issues
- Lifestyle issues
- Reduced carbohydrate intake/ absorption
20
Q
What are 12 medical issues that are risk factors for hypoglycaemia?
A
- Strict glycaemic control
- Previous history of severe hypoglycaemia
- Long duration of type 1 diabetes
- Duration of insulin therapy in type 2 diabetes
- Lipohypertrophy at injection sites
- Impaired awareness of hypoglycaemia
- Severe hepatic dysfunction
- Impaired renal function (including those patients requiring renal replacement therapy)
- Sepsis
- Inadequate treatment of previous hypoglycaemia
- Terminal illness
- Cognitive dysfunction/dementia
21
Q
What are 7 lifestyle issues that are risk factors for hypoglycaemia?
A
- Increased exercise (relative to usual)
- Irregular lifestyle
- Alcohol
- Increasing age
- Early pregnancy
- Breast feeding
- No or inadequate blood glucose monitoring
22
Q
What are 2 examples of reduced carbohydrate intake/absorption that are risk factors for hypoglycaemia?
A
- Food malabsorption e.g. gastroenteritis, coeliac disease
- Bariatric surgery involving bowel resection
23
Q
What are 3 demographic risk factors associated with hypoglycaemia?
A
- Age >70 years
- Cognitive dysfunction
- Nephropathy
24
Q
What are 10 types of medicatino that, when used with hypoglycaemic agents, can precipitate hypoglycaemia?
A
- warfarin
- quinine
- salicylates
- fibrates
- sulphonamides (including cotrimoxazole)
- monoamine oxidase inhibitors
- NSAIDs
- probenecid
- somatostatin analogues
- SSRIs
25
What should you do if a patient is taking a medication that you feel could precipitate hypoglycaemia, in combination with hypoglycaemic agents?
do not stop or withhold medication, discuss with the medical team or pharmacist
26
What are 4 examples of loss of counter-regulatory hormonal function that can precipitate hypoglycaemia?
1. Addison's disease
2. Growth hormone deficiency
3. Hypothyroidism
4. Hypopituitarism
27
What are 6 examples of prescription errors that can precipitate inpatient hypoglycaemia?
1. Misreading poorly written prescriptions e.g. U is used for units
2. Confusing the insulin name with the dose (e.g. Humalog Mix25 becoming Humalog 25 units)
3. Confusing the insulin strength with the dose (e.g. 100 unit dose inadvertently prescribed)
4. Transcription errors (e.g. where patient on animal insulin is inadvertently prescribed human insulin or where handwriting is unclear)
5. Inappropriately withdrawing insulin using a standard insulin syringe (100 units/ml) from prefilled insulin pens containing higher insulin concentrations e.g. 200units/ml or 300units/ml
6. Confusion btw prescription of glucose and insulin infusion for hyperkalaemia (10 units insulin in 50ml 50% dextrose) and glucose and insulin infusion to control blood glucose (50 units in 50ml normal saline)
28
What are 12 medical issues which can cause inpatient hypoglycaemia?
1. Inappropriate use of ‘stat’ or ‘PRN’ rapid/short acting insulin
2. Acute discontinuation of long term corticosteroid therapy
3. Recovery from acute illness/stress
4. Mobilisation after illness
5. Major amputation of a limb
6. Incorrect type of insulin or oral hypoglycaemic therapy prescribed and administered
7. Inappropriately timed insulin or oral hypoglycaemic therapy in relation to meal or enteral feed
8. Change of insulin injection site
9. IV insulin infusion with or without glucose infusion
10. Inadequate mixing of intermediate acting or mixed insulins
11. Regular insulin doses or oral hypoglycaemia therapy being given in hospital when these are not routinely taken at home
12. Failure to monitor blood glucose adequately whilst on IV insulin infusion
29
What are 9 carbohydrate intake issues which can cause hypoglycaemia?
1. Missed or delayed meals
2. Less carbohydrate than normal
3. Change of the timing of the biggest meal of the day (i.e. main meal at midday rather than evening)
4. Lack of access to usual between meal or before bed snacks
5. Prolonged starvation time e.g. ‘Nil by Mouth’
6. Vomiting
7. Reduced appetite
8. Reduced carbohydrate intake
9. Omitting glucose whilst on IV insulin infusion
30
What are 4 examples of morbidity associated with hypoglycaemia?
1. Coma
2. Hemiparesis
3. Seizures
4. If prolonged, neurological deficits can become permanent
31
What are 2 disadvantages of episodes of inpatient hypoglycaemia in addition to the examples of associated mortality?
1. Patients on insulin therapy remain in hospital for longer if they experience hypoglycaemia
2. Greater inpatient mortality if experience hypoglycaemia
32
What is impaired awareness of hypoglycaemia (IAH)?
acquired syndrome associated with insulin treatment
results in warning symptoms of hypoglycaemia becoming diminished in intensity, altered in nature or lost altogether, increasing vulnerablility to progression to severe hypoglycaemia
33
What are 2 risk factors for impaired awareness of hypoglycaemia (IAH)?
1. Longer duration of diabetes
2. More common in type 1 vs type 2 diabetes
34
What is the overall approach to management of hypoglycaemia?
need to give quick acting carbohydrate to return blood glucose levels to normal range, followed by giving long acting carbohydrate, either as a snack or as part of a planned meal
35
What key investigation should be performed in suspected hypoglycaemia and when?
blood glucose measurement to confirm hypoglycaemia - if safe to do so
(especially if suspicion person may be under influence of alcohol)
36
What should you do if it is difficult to perform a blood glucose measurement e.g. patient is having a seizure?
treatment should not be delayed
37
After the acute treatment of hypoglycaemia, what should next be considered about further treatment?
whether the hypoglycaemia is likely to be prolonged i.e. as a result of long acting insulin or sulfonylurea therapy - these patients may require continuous infusion of glucose to maintain blood glucose levels
38
What treatment may need to be considered if hypoglyceamia is likely to be prolonged due to long acting insulin/sulfonylurea therapy?
may require continuous infusino of glucose
39
Why is chocolate no longer recomended for the treatment of hypoglycaemia?
contains quick-acting carbohydrate and fat; the addition of fat has been shown to slow the absorption of quick-acting carbohydrate
40
What is the minimum time you should wait before repeating blood glucose measurements while treating hypoglycaemia?
10 minutes (less than this not an adequate amount of time)
41
Why are soft drinks like lucozade and ribena no longer recommended to treat hypoglycaemia?
sugar tax means formulations have changed so don't contain enough sugar now (products designed specifically for hypos will be exempt from sugar tax)
42
In which people will IM glucagon be less effective to treat hypoglycaemia?
those with depleted glycogen reserves - e.g. with impaired hepatic function
43
What are hypo boxes?
boxes often in a prominent place e.g. on resuscitation trolleys, brightly coloured for instant recognition
contain all the equipment required to treat hypoglycaemia - cartons of fruit juice ot IV cannulas
44
What is the treatment of choice of hypoglycaemia in patients who are conscious and able to swallow?
15-20g of fast acting carbohydrate
45
If adults are experiencing hypoglycaemia symptoms but have a blood glucose level \>4.0mmol/L what is the management?
treat with small carbohydrate snack only e.g. 1 medium banana, a slice of bread or normal meal if due
46
How does the guidance for management of hypos in the community setting differ from the inpatient guidance?
DAFNE: dose-adjustment for normal eating is a course for people with T1DM to teach patients to adjust insulin according to carbohydrate consumption, suggests hypoglycaemia is treated at level of 3.5 mmol/L rather than \<4mmol/L
47
What are 7 aspects to the management of hypoglycaemia in a patient who is conscious, orientated and able to swallow?
1. **Give 15-20g quick acting carbohydrate**
2. Repeat capillary blood glucose measurement **10-15 min later.** If still, \<4.0mmol/L, repeat step 1
3. If blood glucose \<4.0mmol/L after 30-45min or 3 cycles, contact a doctor and consider:
* **1mg of glucagon IM**
* **150-200ml of 10% glucose over 15 min (e.g. 600-800ml/hr)**
4. **Once above 4.0mmol/L, give long acting carbohydrate**
5. Do not omit insulin injection if due
6. Document even in patient's notes
7. Continue regular capillary blood glucose monitoring for at least 24-48h
48
What are 4 examlpes of 15-20g of quick-acting carbohydrate to use for patients who are consciousn, oriented and able to swallow?
1. 5-7 Dextrosol tablets (or 4-5 Glucotabs)
2. 1 bottle (60ml) Glucojuice
3. 150-200ml pure fruit juice e.g. orange
4. 3-4 heaped teaspoons of sugar dissolved in water
49
In which patients should orange juice not be used as the quick-acting carbohydrate to treat hypoglycaemia?
patients following a low potassium diet e.g. due to chronic kidney disease, due to its potasisum content
50
In which patients is heaped teaspoons of sugar dissolved in water not an effective treatment for hypoglycaemia?
patients taking acarbose - it prevents the breakdown of sucrose to glucose
generally should only consider it if no other treatment options are available
51
When you repeat capillary glucose after treating hypoglyceamia in conscious, oriented patients able to swallow, what should you do if the reading is still less than 4.0mmol/L?
repeat giving 15-20g of quick acting carbohydrate; no more than 3 treatments in total
52
What are 2 options for if 15-20g quick acting carbohydrate has been given 3 times in a patient who is consious, oriented and able to swallow?
1. 1mg IM glucagon
2. 150-200ml 10% glucose over 15 min (600-800 ml/hr)
53
What should you be careful about when administering 150-200ml of IV glucose to treat hypoglycaemia in patients who are conscious, orientated and able to swallow?
be careful if larger volume bags are used that the whole bag isn't inadvertently administered
54
What are 4 examples of long-acting carbohydrate to give in hypoglycaemia once blood glucose is \>4mmol/L in adults who are conscious, orientated and able to swallow?
1. Two biscuits
2. One slice of bread /toast
3. 200-300ml glas of milk (not soya)
4. Normal meal if due (must contain carbohydrate)
55
When might patients require a larger portion of long-acting carbohydrate to replenish glycogen stores after treating patients for hypoglycaemia with oral glucose?
if IM glucagon has been given
56
What is a side effect of IM glucagon injections?
nausea
57
How does the management of patients with hypoglycaemia with oral glucose for patients who have insulin pumps (CSII - continuous subcutaneous insulin infusion) differ?
may not need a long-acting carbohydrate
should take initial treatment as outlined and adjust their pump settings appropriately
58
How long can hypoglycaemia persist for if the cause was long-acting insulin therapy or a sulfonylurea?
may be for up to 24-36 hours following the last dose (especially if concurrent renal impairment)
59
For how long should regular capillary blood glucose monitoring be continued following treatment for hypoglycaemia?
at least 24-48 hours
60
If a patient is discharged following treatment for hypoglycaemia but this is before 24-48h of blood glucose monitoring has passed what should be done?
ask the patient to continue this at home
give hypoglycaemia education/refer to local Diabetes Inpatient Team
61
How does the initial management of hypoglycaemia change if the patient is conscius but confused, disorientated, unable to cooporate or aggressive but able to swallow? 2 options
* **_1.5-2 tubes 40g glucose gel (Glucogel)_** squeezed into the mouth between the teeth and gums **or**
* (if this is ineffective) give **_Glucagon 1mg IM_**
62
When treating hypoglycaemia in a patient who is confused/ disorientated/unable to cooperate but able to swallow, when should you repeat the blood glucose measurement and how many times can you repeat the treatment?
* repeat measurement after 10-15 min
* repeat treatment up to twice i.e. no more than 3 treatments in total and **only give IM glucagon once**
63
If blood glucose remains \<4.0mmol/L after 30-45 mins when treating a patient who is able to swallow but is confused/ uncooperative/ aggressive what should you do next?
contact doctor, consider IV glucose (150-200ml of 10% glucose over 15 min at infusion rate of 600-800ml/hr)
64
How should the long-acting carbohydrate given to the patient following intial treatment of hypoglycaemia differ if the patient has been given glucagon?
larger portion of long-acting carbohydrate should be given - double suggested amount
65
What are 9 steps to the management of hypoglycaemia in a patient who is unconscious and/or having seizures and/or very aggressive?
1. **ABC assessment (including giving oxygen, GCS, blood glucose, temperature)**
2. **If the patient has an insulin infusion in situ, stop this immediately**
3. Request immediate assistance from medical staff e.g. fast bleep a doctor
4. **if IV access available give 75-100ml of 20% or 10% glucose over 15 min. if no IV access available then give 1mg glucagon IM**
5. once blood glucose \>4 and patient recovered, give long acting carbohydrate
6. do not omit insulin injection if due
7. **if patient was on IV insulin, continue to check blood glucose every 15 minutes until above 3.5 mmol/L then re-start IV insulin after review of dose regimen to try and prevent hypo recurrence. consider concurrent IV 10% glucose infsuino at 100ml/hr and/or stepping donw insulin increments on the variable scale if appropriate**
8. if hypoglycaemia was due to sulfonylurea or long acting insulin therapy, be aware risk of hypos may persist for up to 24-36 hours following the last dose, especially if concurrent renal impairment
9. document event in patient's notes. ensure regular capillary blood glucose monitoring is continued for at least 24-48h
66
Following A to E assessment, what are the key aspects of initial management of hypoglycaemia in a patient who is unconscious/have seizures/aggressive? 3 key options
* if receiving insulin infusion, stop immediately
* one of the following 3:
* if IV access: **75-100ml of 20% glucose over 15 min (300-400ml/hr).** if infusion pump is available use this, if not do not delay the infusion
* if IV access: **150-200ml of 10% glucose over 15 min (600-800ml/hr).** if infusion pump available use, if not don't delay infusion
* if no IV access available, give **1mg glucagon IM**
67
What are 3 situations when IM glucagon will be less effective to treat hypoglycaemia?
1. Chronically malnourished
2. Alcohol abuse
3. Severe liver disease
68
What should you do following the management of hypoglycaemia if the patient was on IV insulin?
continue to check blood glucose every 15 min until above 3.5 mmol/L, then restart the IV insulin after review of dose regimen to try and prevent hypo recurrence
consider concurrent IV 10% glucose infusion at 100ml/hour and/or stepping down the insulin increments on the variable scale if appropriate
69
If a patient is nil by mouth experiences hypoglycaemia, how does the management change?
same other than:
* if have a variable rate IV i**nsulin infusion, adjust as per prescribed regimen and seek medical advice**
* most VRIIs should be restarted once blood glucose is above 4.0 mmol/L although an infusion rate adjustment may be indicated
* either:
* **IV glucose 20% 75-100ml over 15 min or**
* **IV glucose 10% 150-200ml over 15 min**
70
For nil by mouth patients with hypoglycaemia, what should be done if they were previously receiving a variable rate insulin infusion, following successful treatment?
most VRIIs should be restarted once blood glucose \>4.0mmol/L, but infusion rate adjustment may be indicated
71
What should be done in terms of ongoing glucose for a nil by mouth patient following successful treatment of hypoglyceamia?
once blood glucose \>4 and patient recovered, consider **IV infusion of 10% glucose at rate of 100ml/hr** until patient no longer nil by mouth/ has been reviewed by doctor
72
What should be done for all diabetic patients requiring total parenteral nutrition?
should be referred to a dietitian/ nutrition team and diabetes team for individual assessment
73
For diabetic patients requiring enteral/parenteral feeding, what are 10 risk factors for hypoglycaemia?
1. Blocked/displaced tube
2. Change in feed regimen
3. Enteral feed discontinued
4. TPN or IV glucose discontinued
5. Diabetes medication administered at an inappropriate time to feed
6. Changes in medication that cause hyperglycaemia e.g. steroid therapy reduced/stopped
7. Feed intolerance
8. Vomiting
9. Deterioration in renal function
10. Severe hepatic dysfunction
74
Via which routes should treatment for hypoglycaemia be administered in patients requiring enteral/parenteral feeding?
orally/ via feed tube or intravenously as appropriate, **not** via TPN line
75
What are the 2 key differences when treating hypoglycaemia in a patient requiring enteral/parenteral feeding?
1. Give **15-20g quick acting carbohydrate** via feeding tube (NG/gastrostomy), **followed by 40-50ml water flush of the feeding tube** to prevent blockage
2. once blood glucose is above 4mmol/L and patient recovered:
* restart feed
* if bolus feeding, give additional bolus feed (read nutritional information and calculate amount required to give 20g of carbohydrate
* 10% IV glucose at 100ml/hr, volume determined by clinical circumstances
76
What are 7 things to do once hypoglycaemia has been successfully treated?
1. complete audit form and send to DISN, restock hypo boxes as appropriate
2. identify risk factor or cause
3. take measures to avoid hypos in future, can contact Diabetes Team to discuss
4. Medical or DISN review should be considered unless cause easily identifiable and steps can be taken to avoid in future
5. **_Do not_ omit next insulin injection or start VRII to stabilise blood glucose**
6. Medical team or DISN to consider reducing dose of insulin
7. **_Do not_ treat isolated spokes of hyperglycaemia with 'stat' doses of rapid acting insulin, instead maintain regular capillary blood glucose monitoring and adjust normal insulin regimen only if a particular pattern emerges**
77
To summarise, what are the key points of management of hypoglycaemia in the following scenarios:
1. conscious, orientated and able to swallow
2. conscious but confused, disorientated, unable to cooperate or aggressive but able to swallow
3. unconscious and/or seizures and/or very aggressive
4. nil by mouth
5. requiring enteral/parenteral feeding?
1. 15-20g quick acting carbohydrate, repeat up to 3 times, then IM glucagon or 150-200ml 10% glucose IV
2. 1.5-2 tubes 40% Glucogel into mouth or glucagon 1mg IM, repeat glucogel up to 3 times then IV glucose 150-200ml 10% glucose over 15min
3. A to E, stop insulin infusion, 75-100ml 20% glucose or 150-200ml 10% glucose over 15min or IM glucagon 1mg
4. 75-100ml 20% glucose or 150-200ml 10% glucose over 15min
5. 15-20g quick acting carbohydrate, repeat up to 3 times then 150-200ml 10% glucose over 10 min
78
What are 5 options for quick-acting carbohydrate to use for patients requiring enteral/parenteral feeding when treating hypoglycaemia?
1. 1.5-2 tubes 40% glucose gel (Glucogel)
2. 1 bottle (60ml) Glucojuice
3. 150-200ml orange juice
4. 110-140ml Fortijuice (NOT Fortisip) to give 15-20g carbohydrate
5. Re-start feed to rapidly deliver 15-20g carbohydrate
AIP: Diabetic emergencies
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